- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,993.72 / $3,706.14 / $3,955.04
| Facility | | $2,993.72 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.94 / $1,316.56 / $1,525.76
| Professional | | $937.94 | $1,316.56 | $1,525.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.25 / $1,232.18 / $1,968.25
| Professional | | $890.25 | $1,232.18 | $1,968.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.53 / $1,651.96 / $2,122.82
| Professional | | $1,283.53 | $1,651.96 | $2,122.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,713.00 / $7,457.00 / $12,945.00
| Facility | | $3,713.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.84 / $1,471.47 / $2,232.75
| Professional | | $937.84 | $1,471.47 | $2,232.75 |